Case Western Reserve University med students learn from one another

Tuesday August 18, 2009, 9:00 AM

John Kuntz/The Plain DealerCase Western Reserve University School of Medicine's sophomore medical student Andrew Thomas Lenis, center, teaches a group of first year medical students.

While Washington struggles to redefine the nation's health care system, a handful of medical schools across the country have begun changing how they train their doctors.

The change is evident from the start of the school year at Case Western Reserve University School of Medicine, as a group of students in hospital scrubs shuffles into a brightly lighted meeting room. It isn't your typical first-year medical school anatomy lecture.

For one, there is no professor in sight.

Two students lie on a table, watching warily as two of their peers cautiously palpate their abdomens. Another student works to locate his own sternum. "Found it," he says, encouraging a fellow student to feel his breastbone. Three others knock repeatedly on the table, practicing the percussion technique doctors use to check internal organs.

Video: Case Western Reserve University School of Medicine students take part in peer teaching.

At the front of the conference room, Andrew Lenis, a second-year medical school student, quietly surveys the fresh-faced group of eight first-years, who arrived on campus mid-July.

The introductory anatomy class, taught entirely in small groups by second-years, represents CWRU's first foray into peer teaching. After a successful pilot year, the school decided to add histopathology -- the study of tissues in diseases -- to the peer-teaching component of this year's curriculum.

Touted by school officials as the "curriculum of the 21st century," the five-week, peer-taught classes -- formerly presented in large lecture halls -- are intended to ease first-years into the rigorous medical school curriculum.

The goal of introducing peer teaching in the curriculum was three-fold, says Terry Wolpaw, the school's associate dean for curricular affairs. The intimate setting allows the 165 first-years to control the pace of the course, it fosters a collaborative spirit among the students early on, and it helps second-years teaching the course to deepen their understanding of the material, Wolpaw explains.

Faculty members periodically sit in on the eight-member classes to monitor the student teachers.

"The skill set students need for the future is different from 50 years ago," Wolpaw says. In the past, students were able to get away with rote memorization. But with ongoing research and discoveries, medical information is constantly changing, and it is more important than ever for students to learn how to grasp new concepts and adapt to the changing field.

Learning from your peers, Wolpaw says, is an integral part of a physician's training after medical school. "Peer teaching from my end is a win-win."

Lenis pulls out a rainbow pack of Sharpies and an extra-large white T-shirt. "Everybody take a Sharpie," he instructs the students, taking a green marker for himself.

"So who wants to wear the T-shirt?" he asks as the room falls into an awkward silence. "C'mon, guys," he urges.

After a moment of hesitation, Nathaniel Moradzadeh obliges and changes out of his scrubs to model the oversize shirt.

Pointing to an anatomy diagram of the upper body projected onto the screen in front of the classroom, Lenis then asks the students to use their markers to outline the body's internal organs and skeletal structure on Moradzadeh's T-shirt.

For the next hour, the students crowd around the first-year for a chance to trace his clavicle and draw his lungs. They turn to Lenis for guidance when they second-guess their artwork.

"No, the fifth rib is at the level of the nipple," Lenis corrects, after which a student gleefully draws two purple circles on his friend's chest, eliciting raucous laughter from the class.

Most students spend their undergraduate years learning in lecture halls, where they compete for faculty attention. When these students arrived at CWRU, they were immediately immersed in a curriculum with a strong focus on what Wolpaw describes as "self-directed, lifelong learning."

After an overhaul in 2006, the curriculum now emphasizes interactive, small-group discussions and patient-based activities. Much of the learning occurs in such classes, which the students call "IQ groups," where faculty members lead case studies.

"We think that in order for somebody to succeed as a doctor, it's not just about knowing enough," Wolpaw says, referring to the days when medical students memorized the textbook to cram for lengthy multiple-choice exams. "It's about being able to constantly learn."

Peer learning, Wolpaw says, diffuses competitive tensions and encourages students to work together -- a skill they will need when they start treating patients. As for the student teachers, "We never learn it as well until we teach it," she says.

While there currently are no plans to expand the peer teaching component of the curriculum, Wolpaw does not rule out that possibility.

Several top medical schools in the nation, including Columbia University and University of California, San Francisco, also have peer teaching components in their curricula.

"It's how physicians learn," says Marc Dickstein, an associate professor of anesthesiology at Columbia who directs its basic science course led by fourth-year students. Fellow doctors often teach students during residency, Dickstein explains. "We're modeling a practice they're going to be engaged in later on in their careers."

To assure the quality of education in classes led by students with little or no teaching experience, faculty provide the peer teachers with detailed packets covering five weeks of introductory course material that "leave little room for error," says Barbara Freeman, an assistant professor of anatomy at CWRU who helped design the school's curriculum. Faculty members are available should student teachers have questions.

Though some faculty are more comfortable with traditional styles of learning, Freeman says most recognize the value of interactive peer teaching.

"Sitting in lecture and having information poured into a hole drilled on the top of your skull is kind of an inefficient use of our students' time," Freeman says.

Eight students in histopathology class mull over an image of a cluster of pink dots and squiggles on their laptop screens. That's what a stained slide of tissue taken from the armpit looks like under a microscope.

The task? Identify different types of cells on the slide.

Lenis moves around the table to answer individual questions. Those who manage to find the elongated fibroblast cells try to help their peers navigate the magnified image. Within five minutes, everyone is able to make sense of the slide.

Histopathology lends itself especially well to small-group learning, says Rachel Katz, a first-year medical student. "You're looking at something so strange, and you've never seen anything like it before," says the graduate of Northwestern University. "It's nice to have a facilitator who can answer personal questions."

Unlike what she describes as the cutthroat environment of her undergraduate pre-med years, the peer-teaching setting allows students to shed their insecurities and feel comfortable asking questions, Katz says.

A fellow student, Chris McCulloh agrees. "I got something wrong today," McCulloh admits. "But this focuses a lot more on understanding the right answer, rather than getting the right answer."

Lenis, who is considering a career in academic medicine, says that he and his fellow peer teachers can relate easily with his class.

"I know what they're thinking because I was just there a year ago," Lenis says. "The point I like to make is, get it wrong now in front of me -- don't get it wrong later when it counts."